Method, apparatus, and computer program product for providing estimated prescription costs

ABSTRACT

A method, apparatus and computer program product are provided for providing a patient with prescribed medication cost information at a point of prescribing. A prescription benefit coverage inquiry is received and provided to a claims processor for processing. Historical data associated with prior prescription transactions is utilized to determine an estimated cost range of a prescribed medication in the event of an insufficient or absent response from a benefits manager. The estimated cost range is then provided to a prescriber to share with a patient.

TECHNOLOGICAL FIELD

Embodiments of the present invention relate generally to healthcaretransactions and, more particularly, to methods, apparatuses, andcomputer program products for providing estimated costs for prescribedmedication.

BACKGROUND

In the healthcare services industry, patients may appreciate discussingcosts of a prescribed medication with their physician or otherprescriber during the service and prior to obtaining the prescription ata pharmacy so different medication options may be considered. However,physicians and other prescribers may not always have accurateinformation available to them during the service regarding costs of themedication. Providing the costs of such prescriptions to prescribersduring the service can be a challenge with today's healthcare providersystems as benefit coverage inquiries continue to evolve. Over time, thefinancial structures for prescription claims have become moresophisticated (i.e. formulary tiers, deductibles, maximum benefits,etc.), and prices can vary greatly between pharmacies.

BRIEF SUMMARY

Methods, apparatuses, and computer program products are thereforeprovided for supplying a prescriber at the point of prescribing (e.g.,during a healthcare service with a patient) with information to provideto a patient, and particularly for providing estimated prescriptioncosts in the event of an insufficient or absent response from a benefitsmanager. Current attempts at providing pricing information at theprescriber during a service may involve inquiring and obtaining aresponse from a patient's benefits manager (e.g. insurance companyand/or payor) to provide the patient with accurate informationconcerning prescription costs and out-of-pocket expenses prior tovisiting a pharmacy. However, problems may arise when a response fromthe pharmacy benefits manager is lacking certain required information,or, in some instances, when a response is not provided, or not providedwithin a specified time period.

An apparatus is provided, comprising at least one processor and at leastone memory including computer program code, the at least one memory andthe computer program code configured to, with the processor, cause theapparatus to at least receive, from a prescriber computer, aprescription benefit coverage inquiry associated with a patient and aprescribed medication. The at least one memory and the computer programcode may be further configured to, with the processor, cause theapparatus to transmit the prescription benefit coverage inquiry to apharmacy claims processor computer for processing.

The at least one memory and the computer program code may be furtherconfigured to, with the processor, cause the apparatus to determine,based on historical data comprising prior prescription transactionsassociated with the prescribed medication, an estimated cost range forthe prescribed medication. The at least one memory and the computerprogram code may be further configured to, with the processor, cause theapparatus to provide the estimated cost range for the prescribedmedication to the prescriber computer for display to a user. Accordingto certain embodiments, the at least one memory and the computer programcode may be configured to, filter the historical data so as to excludeone or more types of prescription transactions from consideration.

In certain embodiments, determining the estimated cost range may furthercomprise determining an average value based on a paid amount associatedwith each of the prescription transactions in the historical data,identifying a subset of prescription transactions from the historicaldata based on the average value, and, from the subset of prescriptiontransactions, determining the estimated cost range of the prescribedmedication that ranges a calculated amount from the average value.

In some embodiments, identifying a subset of prescription transactionsfrom the historical data based on the average value may further comprisecomparing each paid amount to a calculated amount associated with theaverage value to determine one or more paid amounts that are within apredefined range of the calculated amount, and including, based on thecomparison, transactions comprising paid amounts within the predefinedrange of the calculated amount in the subset of prescriptiontransactions.

In certain embodiments, the at least one memory and the computer programcode may be configured to, with the processor, cause the apparatus toperform providing the estimated cost range for the prescribed medicationto the prescriber computer for display to a user relative to receiving aprescription benefit coverage inquiry associated with a patient and aprescribed medication in real-time or near real-time.

The at least one memory and the computer program code may be furtherconfigured to, with the processor, cause the apparatus to monitor forreceipt of a response associated with the prescription benefit coverageinquiry. The at least one memory and the computer program code may befurther configured to cause the apparatus to determine, in an instancein which the response associated with the prescription benefit coverageinquiry fails to be received by the one or more service providercomputers in a predefined amount of time, that a timeout has occurred.

A method is also provided, the method including receiving, from aprescriber computer, a prescription benefit coverage inquiry associatedwith a patient and a prescribed medication. The method may also includetransmitting the prescription benefit coverage inquiry to a pharmacyclaims processor computer for processing.

The method may further include determining, based on historical datacomprising prior prescription transactions associated with theprescribed medication, an estimated cost range for the prescribedmedication. The method may further include providing the estimated costrange for the prescribed medication to the prescriber computer fordisplay to a user. According to certain embodiments, the method may alsoinclude filtering the historical data so as to exclude one or more typesof prescription transactions from consideration.

In certain embodiments of the method, determining the estimated costrange may further comprise determining an average value based on a paidamount associated with each of the prescription transactions in thehistorical data, identifying a subset of prescription transactions fromthe historical data based on the average value, and, from the subset ofprescription transactions, determining the estimated cost range of theprescribed medication that ranges a calculated amount from the averagevalue.

In some embodiments of the method, identifying a subset of prescriptiontransactions from the historical data based on the average value mayfurther comprise comparing each paid amount to a calculated amountassociated with the average value to determine one or more paid amountsthat are within a predefined range of the calculated amount, andincluding, based on the comparison, transactions comprising paid amountswithin the predefined range of the calculated amount in the subset ofprescription transactions.

In certain embodiments, the method may perform providing the estimatedcost range for the prescribed medication to the prescriber computer fordisplay to a user relative to receiving a prescription benefit coverageinquiry associated with a patient and a prescribed medication inreal-time or near real-time.

The method may further include monitoring for receipt of a responseassociated with the prescription benefit coverage inquiry. The methodmay also include determining, in an instance in which the responseassociated with the prescription benefit coverage inquiry fails to bereceived by the one or more service provider computers in a predefinedamount of time, that a timeout has occurred.

A computer program product is also provided, the computer programproduct comprising at least one non-transitory computer-readable storagemedium having computer-executable program code instructions storedtherein, the computer-executable program code instructions comprisingprogram code instructions to receive, from a prescriber computer, aprescription benefit coverage inquiry associated with a patient and aprescribed medication. The computer-executable program code instructionsmay further include program code instructions to transmit theprescription benefit coverage inquiry to a pharmacy claims processorcomputer for processing.

The computer-executable program code instructions may further includeprogram code instructions to determine, based on historical datacomprising prior prescription transactions associated with theprescribed medication, an estimated cost range for the prescribedmedication. The computer-executable program code instructions mayfurther include program code instructions to provide the estimated costrange for the prescribed medication to the prescriber computer fordisplay to a user. According to certain embodiments, thecomputer-executable program code instructions may further includeprogram code instructions to filter the historical data so as to excludeone or more types of prescription transactions from consideration.

In certain embodiments of the computer program product, determining theestimated cost range may further comprise determining an average valuebased on a paid amount associated with each of the prescriptiontransactions in the historical data, identifying a subset ofprescription transactions from the historical data based on the averagevalue, and, from the subset of prescription transactions, determiningthe estimated cost range of the prescribed medication that ranges acalculated amount from the average value.

In some embodiments of the computer program product, identifying asubset of prescription transactions from the historical data based onthe average value may further comprise comparing each paid amount to acalculated amount associated with the average value to determine one ormore paid amounts that are within a predefined range of the calculatedamount, and including, based on the comparison, transactions comprisingpaid amounts within the predefined range of the calculated amount in thesubset of prescription transactions.

In certain embodiments, the computer-executable program codeinstructions may further include program code instructions to performproviding the estimated cost range for the prescribed medication to theprescriber computer for display to a user relative to receiving aprescription benefit coverage inquiry associated with a patient and aprescribed medication in real-time or near real-time.

The computer-executable program code instructions may further includeprogram code instructions to monitor for receipt of a responseassociated with the prescription benefit coverage inquiry. Thecomputer-executable program code instructions may further includeprogram code instructions to cause the apparatus to determine, in aninstance in which the response associated with the prescription benefitcoverage inquiry fails to be received by the one or more serviceprovider computers in a predefined amount of time, that a timeout hasoccurred.

An apparatus is provided with means for receiving, from a prescribercomputer, a prescription benefit coverage inquiry associated with apatient and a prescribed medication. The apparatus may further includemeans for transmitting the prescription benefit coverage inquiry to apharmacy claims processor computer for processing.

The apparatus may further include means for determining, based onhistorical data comprising prior prescription transactions associatedwith the prescribed medication, an estimated cost range for theprescribed medication. The apparatus may further include means forproviding the estimated cost range for the prescribed medication to theprescriber computer for display to a user. According to certainembodiments, the apparatus may further include means for filtering thehistorical data so as to exclude one or more types of prescriptiontransactions from consideration.

In certain embodiments, determining the estimated cost range may furthercomprise determining an average value based on a paid amount associatedwith each of the prescription transactions in the historical data,identifying a subset of prescription transactions from the historicaldata based on the average value, and, from the subset of prescriptiontransactions, determining the estimated cost range of the prescribedmedication that ranges a calculated amount from the average value.

In some embodiments, identifying a subset of prescription transactionsfrom the historical data based on the average value may further comprisecomparing each paid amount to a calculated amount associated with theaverage value to determine one or more paid amounts that are within apredefined range of the calculated amount, and including, based on thecomparison, transactions comprising paid amounts within the predefinedrange of the calculated amount in the subset of prescriptiontransactions.

In certain embodiments, the apparatus may further include means forperforming providing the estimated cost range for the prescribedmedication to the prescriber computer for display to a user relative toreceiving a prescription benefit coverage inquiry associated with apatient and a prescribed medication in real-time or near real-time.

The apparatus may further include means for monitoring for receipt of aresponse associated with the prescription benefit coverage inquiry. Theapparatus may further include means for determining, in an instance inwhich the response associated with the prescription benefit coverageinquiry fails to be received by the one or more service providercomputers in a predefined amount of time, that a timeout has occurred.

The above summary is provided merely for purposes of summarizing someexample embodiments of the invention so as to provide a basicunderstanding of some aspects of the invention. Accordingly, it will beappreciated that the above described example embodiments are merelyexamples and should not be construed to narrow the scope or spirit ofthe disclosure in any way. It will be appreciated that the scope of thedisclosure encompasses many potential embodiments, some of which will befurther described below, in addition to those here summarized.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

Having thus described embodiments of the invention in general terms,reference will now be made to the accompanying drawings, which are notnecessarily drawn to scale, and wherein:

FIG. 1 is an example overview of a system that can be used to practicesome example embodiments described herein;

FIG. 2 is an exemplary schematic diagram of an apparatus in accordancewith some example embodiments; and

FIGS. 3-4 are flowcharts of operations that may be performed inaccordance with some example embodiments.

DETAILED DESCRIPTION

Some embodiments of the present invention will now be described morefully hereinafter with reference to the accompanying drawings, in whichsome, but not all embodiments of the invention are shown. Indeed,various embodiments of the invention may be embodied in many differentforms and should not be construed as limited to the embodiments setforth herein; rather, these embodiments are provided so that thisdisclosure will satisfy applicable legal requirements. Like referencenumerals refer to like elements throughout.

As used herein, where a computing device is described herein to receivedata from another computing device, it will be appreciated that the datamay be received directly from the other computing device and/or may bereceived indirectly via one or more intermediary computing devices, suchas, for example, one or more servers, relays, routers, network accesspoints, and/or the like. Similarly, where a computing device isdescribed herein to transmit data to other computing device, it will beappreciated that the data may be sent directly to the other computingdevice or may be sent to the other computing device via one or moreinterlinking computing devices, such as, for example, one or moreservers, relays, routers, network access points, and/or the like.

FIG. 1 is an overview of a system that can be used to analyzeprescription transactions and provide estimated cost ranges ofprescriptions according to certain example embodiments described herein.The prescriber computer 104 may be associated with a healthcareprovider, such as an entity that may prescribe medication and/ortreatments, for example, a physician's office, clinic, long-term carefacility, hospital, etc. While the exemplary prescriber computer 104 maybe frequently referenced herein as part of a physician's office orhealthcare network, the prescriber computer 104 may be associated withany other healthcare provider, such as a hospital, urgent care center,dentist, and/or other medical facility.

The prescriber computer 104 may be any processor-driven device thatfacilitates the processing of prescription benefit coverage inquiriesmade by physicians or clinical staff, and the communication ofinformation associated with prescription benefit coverage inquiries tothe service provider computer 106. The execution of thecomputer-implemented instructions by the prescriber computer 104 and/orservice provider computer 106 may form a special purpose computer orother particular machine that is operable to facilitate the processingof prescription benefit coverage inquiries made by physicians, doctors,clinical staff, pharmacists, and/or the like, and the communication ofinformation associated therewith to a service provider computer and/orclaims processor computer 108.

The service provider computer 106 may include, but is not limited to, aprocessor-driven device that is configured for receiving, processing,and fulfilling inquiries, responses, and/or requests from the prescribercomputer 104 and/or the claims processor computer 108 (described below),relating to prescription benefit coverage inquiries, prescriptiontracking, claims processing, benefits, billing, other healthcaretransactions, and/or other related activities. Additionally oralternatively, the service provider computer 106 may be operable tofacilitate the receipt, routing, and/or processing of prescriptionbenefit coverage inquiries and/or associated responses amongst variouscomponents and/or subsystems such as, but not limited to, those depictedin FIG. 1 .

In certain exemplary embodiments, the service provider computer 106 maybe configured as or may comprise a switch or router that evaluates,processes, modifies, reformats, generates, and/or routes prescriptionbenefit coverage inquiries and/or other healthcare transactions. Forexample, the service provider computer 106 may route prescriptionbenefit coverage inquiries communicated from the prescriber computer 104to a claims processor computer 108, such as that associated with apharmacy benefits manager (PBM), an insurer, a Medicare or othergovernment healthcare insurance program payor, or other payor.

Additionally or alternatively, the service provider computer 106 mayreformat prescription benefit coverage inquiries into another form oftransaction and modify the recipient information of the reformattedtransaction before routing the reformatted transaction to another party,such as a claims processor computer 108. The service provider computer106 may also direct a prescription benefit coverage inquiry to a claimsprocessor computer 108, which may in turn route a response to theservice provider computer 106. The service provider computer 106 maythen direct the response to the prescriber computer 104 or otherassociated entity.

In addition to receiving and storing information, the service providercomputer 106 may be further operable to access and/or be incommunication with one or more suitable data storage devices, such as adatabase 102, for storing historical data and/or other various data. Insome embodiments, the database 102 comprises data relating toprescription transactions associated with one or more pharmacy computers110. Data, such as for example, historical data, may be provided byand/or stored in database 102 by a number of entities which may comprisethe prescriber computer 104, service provider computer 106, claimsprocessor computer 108, one or more pharmacy computers 110 and/or otherrelated entities. In certain embodiments, data is provided to database102 by one or more pharmacy computers 110 associated with one or morepharmacies. These one or more pharmacy computers 110 may voluntarilyprovide data to database 102 (and/or service provider computer 106,which may in turn store the historical data on database 102), such ashistorical data related to prior prescription transactions that havetaken place at each respective pharmacy. In this regard, the historicaldata may comprise paid amounts by consumers (e.g., patients) atparticular pharmacies for particular prescriptions, and may reflect cashprices (without any insurance payment or coverage), and/or may reflectpaid amounts by the consumer given a paid and/or adjudicatedprescription claim by the claims processor computer 108. In anembodiment, the one or more pharmacies may be taking part in a programwherein certain data is supplied to database 102 by the one or morepharmacy computers 110 associated with the one or more pharmacies in aneffort to provide patients and prescribers with accurate costinformation at a point of prescribing. According to some embodiments,the historical data may indicate other characteristics about respectiveprescription transactions, such as the state or other locationinformation of the dispensing pharmacy, the dispense date, informationregarding preauthorization requirements, and/or the like. The serviceprovider computer 106 may be configured to mine and store pertinentinformation from any healthcare transactions and/or claims receivedand/or generated by the service provider computer 106, particularly datathat may utilized by example embodiments described herein to estimatecost ranges of prescriptions.

The service provider computer 106 may transmit responses regarding theprescription benefit coverage inquires to the prescriber computer 104.For example, the service provider computer 106 may notify the prescribercomputer 104 of and/or provide a response related to a prescriptionbenefit coverage inquiry from the claims processor computer 108, such asthe amount the patient should expect to pay for the prescription at agiven pharmacy. However, according to some example embodiments, aresponse from the claims processor computer 108 may not be received, andthe service provider computer 106 may provide a cost estimate of aprescription, as described in further detail below. In this regard, amessage or other notification may be appended to or included in theresponse transmitted to the prescriber computer 104.

The example system of FIG. 1 described above is provided merely as anexample and it will be appreciated that the example embodiments providedherein may be implemented as or employed by any number of systemarchitectures. Some modifications may be made to certain embodiments. Itwill be further appreciated that any of the components of FIG. 1 areconfigured to communicate over a network, or network(s), as described infurther detail herein.

Referring now to FIG. 2 , apparatus 200 is a computing device(s)configured for implementing a prescriber computer 104, service providercomputer 106, pharmacy computer 110, and/or claims processor computer108, according to example embodiments.

Apparatus 200 may at least partially or wholly embody any of theprescriber computer 104, service provider computer 106, pharmacycomputer 110, and/or claims processor computer 108. Apparatus 200 maytherefore implement any of the prescriber computer 104, service providercomputer 106, pharmacy computer 110, and/or claims processor computer108, in accordance with some example embodiments, or may be implementedas a distributed system that includes any of the prescriber computer104, service provider computer 106, pharmacy computer 110, claimsprocessor computer 108, and/or associated network(s).

It should be noted that the components, devices, and elementsillustrated in and described with respect to FIG. 2 may not be mandatoryand thus some may be omitted in certain embodiments. For example, FIG. 2illustrates a user interface 216, as described in more detail below,which may be optional in any of the prescriber computer 104, serviceprovider computer 106, pharmacy computer 110, and/or claims processorcomputer 108. Additionally, some embodiments may include further ordifferent components, devices, or elements beyond those illustrated inand described with respect to FIG. 2 .

Continuing with FIG. 2 , processing circuitry 210 may be configured toperform actions in accordance with one or more example embodimentsdisclosed herein. In this regard, the processing circuitry 210 may beconfigured to perform and/or control performance of one or morefunctionalities of apparatus 200 in accordance with various exampleembodiments. The processing circuitry 210 may be configured to performdata processing, application execution, and/or other processing andmanagement services according to one or more example embodiments. Insome embodiments apparatus 200, or a portion(s) or component(s) thereof,such as the processing circuitry 210, may be embodied as or comprise acircuit chip. The circuit chip may constitute means for performing oneor more operations for providing the functionalities described herein.

In some example embodiments, the processing circuitry 210 may include aprocessor 212, and in some embodiments, such as that illustrated in FIG.2 , may further include memory 214. The processing circuitry 210 may bein communication with or otherwise control a user interface 216, and/ora communication interface 218. As such, the processing circuitry 210,such as that included in any of the prescriber computer 104, serviceprovider computer 106, pharmacy computer 110, claims processor computer108, and/or apparatus 200 may be embodied as a circuit chip (e.g., anintegrated circuit chip) configured (e.g., with hardware, software, or acombination of hardware and software) to perform operations describedherein.

The processor 212 may be embodied in a number of different ways. Forexample, the processor 212 may be embodied as various processing meanssuch as one or more of a microprocessor or other processing element, acoprocessor, a controller, or various other computing or processingdevices including integrated circuits such as, for example, an ASIC(application specific integrated circuit), an FPGA (field programmablegate array), or the like. Although illustrated as a single processor, itwill be appreciated that the processor 212 may comprise a plurality ofprocessors. The plurality of processors may be in operativecommunication with each other and may be collectively configured toperform one or more functionalities of apparatus 200 as describedherein. The plurality of processors may be embodied on a singlecomputing device or distributed across a plurality of computing devicescollectively configured to function as prescriber computer 104, serviceprovider computer 106, pharmacy computer 110, claims processor computer108, and/or apparatus 200. In some example embodiments, the processor212 may be configured to execute instructions stored in the memory 214or otherwise accessible to the processor 212. As such, whetherconfigured by hardware or by a combination of hardware and software, theprocessor 212 may represent an entity (e.g., physically embodied incircuitry—in the form of processing circuitry 210) capable of performingoperations according to embodiments of the present invention whileconfigured accordingly. Thus, for example, when the processor 212 isembodied as an ASIC, FPGA, or the like, the processor 212 may bespecifically configured hardware for conducting the operations describedherein. Alternatively, as another example, when the processor 212 isembodied as an executor of software instructions, the instructions mayspecifically configure the processor 212 to perform one or moreoperations described herein.

In some example embodiments, the memory 214 may include one or morenon-transitory memory devices such as, for example, volatile and/ornon-volatile memory that may be either fixed or removable. In thisregard, the memory 214 may comprise a non-transitory computer-readablestorage medium. It will be appreciated that while the memory 214 isillustrated as a single memory, the memory 214 may comprise a pluralityof memories. The plurality of memories may be embodied on a singlecomputing device or may be distributed across a plurality of computingdevices. The memory 214 may be configured to store information, data,applications, computer program code, instructions and/or the like forenabling apparatus 200 to carry out various functions in accordance withone or more example embodiments. For example, when apparatus 200 isimplemented as service provider computer 106, memory 214 may beconfigured to store computer program code for performing correspondingfunctions thereof, as described herein according to example embodiments.

Still further, memory 214 may be configured to store routing tables,that facilitate determining the destination of communications receivedfrom a prescriber computer 104, and/or claims processor computer 108.Memory 214 may further include reconciliation tables for tracking theprescription benefit coverage inquiries received from the prescribercomputer 104, and reconciling them with responses received from claimsprocessor computer 108. The memory 214 may be modified as describedherein, to store reformatted prescription benefit coverage inquirieswith additional information received, determined and/or generatedaccording to example embodiments.

The memory 214 may be further configured to buffer input data forprocessing by the processor 212. Additionally or alternatively, thememory 214 may be configured to store instructions for execution by theprocessor 212. In some embodiments, the memory 214 may include one ormore databases, such as database 102, that may store a variety of files,contents, or data sets, such as but not limited to historical data.Among the contents of the memory 214, applications may be stored forexecution by the processor 212 to carry out the functionality associatedwith each respective application. In some cases, the memory 214 may bein communication with one or more of the processor 212, user interface216, and/or communication interface 218, for passing information amongcomponents of apparatus 200.

The optional user interface 216 may be in communication with theprocessing circuitry 210 to receive an indication of a user input at theuser interface 216 and/or to provide an audible, visual, mechanical, orother output to the user. As such, the user interface 216 may include,for example, a keyboard, a mouse, a display, a touch screen display, amicrophone, a speaker, and/or other input/output mechanisms. As such, inembodiments in which apparatus 200 implemented as the prescribercomputer 104, the user interface 216 may, in some example embodiments,provide means for user entry of insurance information, patientinformation, details relating to a prescription, and/or the like, andfor provision of information relating to the estimated cost of aprescription, as described in further detail below. The user interface216 may further enable obtaining patient consent for a benefit inquiryto occur according to example embodiments. In some example embodiments,aspects of user interface 216 may be limited or the user interface 216may not be present.

The communication interface 218 may include one or more interfacemechanisms for enabling communication with other devices and/ornetworks. In some cases, the communication interface 218 may be anymeans such as a device or circuitry embodied in either hardware, or acombination of hardware and software that is configured to receiveand/or transmit data from/to a network and/or any other device or modulein communication with the processing circuitry 210. By way of example,the communication interface 218 may be configured to enablecommunication amongst any of prescriber computer 104, service providercomputer 106, pharmacy computer 110, claims processor computer 108,and/or apparatus 200 over a network, and/or to format an electronichealthcare transaction and/or benefit inquiry. Accordingly, thecommunication interface 218 may, for example, include supportinghardware and/or software for enabling wireless and/or wirelinecommunications via cable, digital subscriber line (DSL), universalserial bus (USB), Ethernet, or other methods.

The network, such as the network in which the system of FIG. 1 orcomponents thereof or components described herein may operate, (e.g.,prescriber computer 104, service provider computer 106, pharmacycomputer 110, claims processor computer 108, and/or apparatus 200,and/or the like) may include a local area network, the Internet, anyother form of a network, or in any combination thereof, includingproprietary private and semi-private networks and public networks. Thenetwork may comprise a wired network and/or a wireless network (e.g., acellular network, wireless local area network, wireless wide areanetwork, some combination thereof, and/or the like).

Having now described an example apparatus for implementing exampleembodiments, FIG. 3 is a flowchart illustrating example operations of anapparatus 200, according to some example embodiments. The operations ofFIG. 3 may be performed by apparatus 200, such as with the serviceprovider computer 106 and/or the like.

As shown by operation 302, apparatus 200 may include means, such asprocessor 212, memory 214, communication interface 218, and/or the like,for receiving, at a service provider computer 106 and from a prescribercomputer 104, a prescription benefit coverage inquiry. The prescriptionbenefit coverage inquiry may be generated by a prescriber, such as aphysician and/or other clinical staff, at a prescriber computer 104 andmay be associated with a particular patient, such as a patient beingexamined by the prescriber during the time when the prescription benefitcoverage inquiry is generated and provided by the prescriber computer104. In some examples, a physician may consider multiple differentprescription options, and discussing the different options inconjunction with estimated costs with the patient, may assist thephysician and patient in determining a preferred prescription option. Inthis regard, the prescription benefit coverage inquiry may be generatedin an effort to provide the patient with cost information associatedwith a prescribed medication, drug, treatment, and/or the like at thetime of prescribing.

All too often, a patient is prescribed a medication at a point ofprescribing, such as a physician's office, without knowledge of how oreven if the medication is covered under the patient's present insuranceplan. These scenarios may lead to the patient being uninformed andblindsided by high or inconvenient costs when fulfilling a prescriptionlater on at a pharmacy or other dispensary. Further, this may lead toconsequences such as the patient experiencing frustration, forgoing theprescribed medication, and/or future determent from seeking prescriptionmedications, even in instances when desperately needed. Providing thepatient with information regarding the cost of the prescription duringthe appointment may reduce the likelihood that a patient declines aprescription at the pharmacy due to cost, and therefore may improve thelikelihood of the patient adhering to a prescription because the patienthas an expectation of the cost of a prescription before visiting thepharmacy.

The prescription benefit coverage inquiry may include informationregarding a medication and/or treatment that the prescriber intends toprescribe to the patient. The prescription benefit coverage inquiry mayalso comprise a variety of information, such as, but not limited to:patient demographic information, such as name, date of birth, age,and/or address, insurance/coverage information such as cardholder name,Cardholder ID and/or other identifier, Group ID and/or GroupInformation, prescriber information such as Primary Care Provider ID orother identifier (e.g. NPI code), Primary Care Provider Name, PrescriberID or other identifier (e.g. NPI code, DEA number), patient's PreferredPharmacy or other Healthcare Provider Information (e.g. store name,chain identifier, store address, etc.), various claim information suchas drug, service, or product information (e.g. via National Drug Code(NDC) number), Prescription/Service Reference Number, Date PrescriptionWritten, Diagnosis/Condition, Number of Refills Authorized, and/or thelike.

According to certain embodiments, the service provider computer 106 mayreceive, transmit, and/or process a plurality of prescription benefitcoverage inquiries, such as from one or more prescriber computers 104,on a continual and/or ongoing basis and may process such request inreal-time or near real-time. The term “near” real-time is used toexpress that the inquiry may be processed, and a cost estimate may bedesired within a fraction of a second, or seconds, from the time theprescription benefit coverage inquiry is submitted.

In operation 304, apparatus 200 may include means, such as processor212, memory 214, communication interface 218, and/or the like, fortransmitting a prescription benefit coverage inquiry to a claimsprocessor computer 108 for processing. In certain embodiments, theclaims processor computer 108 may adjudicate or otherwise process theprescription benefit coverage inquiry. For example, the claims processorcomputer 108 may be associated with the patient's PBM, insuranceprovider, and/or the like. In some embodiments, the adjudication maycomprise a determination of whether the medication associated with theprescription benefit coverage inquiry is covered by the patient'sinsurance, and may provide additional medication cost informationrelevant to the patient and/or prescriber.

In operation 305, apparatus 200 may include means, such as processor212, memory 214, and/or the like, for determining whether a response isreceived, from the claims processor computer 108, for providing to theprescriber computer 104. In this regard, in certain embodiments, theapparatus 200 may include means, such as processor 212, memory 214,communication interface 218, and/or the like, for monitoring for receiptof a response associated with the prescription benefit coverage inquirywithin a predetermined amount of time, or time threshold.

For example, the service provider computer 104 may await a response fromthe claims processor computer 108 by monitoring or tracking the time ittakes to receive a response from the claims processor computer and/orhow much time has elapsed since transmitting the response from theservice provider computer to the claims processor computer. In thisregard, a predetermined amount of time used as a time threshold may beconsidered a predefined condition. It should be appreciated, however,that the predetermined amount of time and/or any other predefinedcondition (described below) may be configurable, such as by a user withadministrative rights and/or the like. As an example, a predeterminedamount of time used as a time threshold may be 0.2 seconds. If aresponse is determined to have been received by the service providercomputer 106 within the time threshold, (e.g., by 0.2 seconds of havingtransmitted the benefit coverage inquiry to claims processor computer108), operations proceed to operation 306.

In this regard, the apparatus 200 may include means, such as processor212, memory 214, communication interface 218, and/or the like, forreceiving a response associated with the prescription benefit coverageinquiry. The response may be received, for example, at the serviceprovider computer 106 from a claims processor computer 108. In thisregard, the claims processor computer 108 may generate and provide aresponse associated with the prescription benefit coverage inquiry afteradjudication and/or other processing by the claims processor computer.

If it is determined a response has not have been received by the serviceprovider computer 106 within the time threshold, (e.g., by 0.2 secondsof having transmitted the prescription benefit coverage inquiry toclaims processor computer 108), referred to as a timeout, or no responseis received prescription benefit coverage inquiry, operations proceed tooperation 308, described below. In some examples, the response time maybe too slow such that the predefined condition comprising thepredetermined amount of time is not satisfied, and/or no response isreceived at all relating to the prescription benefit coverage inquiry. Aresponse may not be received for any number of reasons, such as, forexample, one or more errors on behalf of the claims processor computer106, one or more errors associated with the prescription benefitcoverage inquiry, and/or the like.

In operation 306, apparatus 200 may include means, such as processor212, memory 214, and/or the like, for determining whether a responsereceived from the claims processor computer 108 is sufficient forproviding to the prescriber computer 104, as described in further detailbelow. According to certain embodiments, a received response may bedetermined as sufficient for providing to the prescriber computer 104 ifit satisfies one or more predefined conditions. The predefinedconditions may relate a time constraint condition (described above withrespect to the predetermined amount of time and threshold and operation305) and/or data relevancy condition, described below.

In this regard, receiving a response from the claims processor 108within the predetermine amount of time does not necessarily mean theresponse is sufficient for providing to the prescriber computer 104.Responses that are received within the predetermined amount of time maybe further analyzed to determine if the data therein satisfies otherpredefined conditions, such as data relevancy conditions, to determinewhether the response is relevant to a patient and/or prescriber.

In one non-limiting example, the response may include, one or morefields comprising a patient pay amount field populated with a valuereturned by the claims processor computer 106, an estimated out ofpocket range that the patient can expect to pay, returned by the claimsprocessor computer, a pharmacy name field populated with a pharmacy namecorresponding to the submitted service provider ID on the prescriptionbenefit coverage inquiry, a pharmacy street address populated with apharmacy street address corresponding to the submitted service providerID on the prescription benefit coverage inquiry and/or other associatedfields.

In this regard, the response may be determined by the service providercomputer 106 to be sufficient for providing to the prescriber computer104 and/or relevant to a patient and/or prescriber if the responsecomprises a patient pay amount field populated with a value returned bythe claims processor computer 106. This value may indicate a cost thatthe patient may incur when fulfilling a prescription for the medicationassociated with the prescription benefit coverage inquiry. Additionally,a sufficient response may comprise a status or indication that themedication associated with the prescription benefit coverage inquiry iscovered by the patient's pharmacy benefits manager/insurance provider.In one or more embodiments, the determination of a sufficient responsemay comprise parsing the response to identify if one or more fieldscomprise values suitable for provision to a user at the prescribercomputer 104. For example, the service provider computer 106 may parsethe prescription benefit coverage inquiry to determine if the patientpay amount comprises a value greater than or equal to zero, and if so,the response is determined to be sufficient for providing to theprescriber computer 104. If a specific value such as the patient payamount is NULL, or less than zero, it may be determined that theresponse is not sufficient for providing to the prescriber computer 104,and processing continues at operation 38. It will be appreciated thatany other fields in the response may be analyzed and/or processedrelative to a predefined condition, to determine whether the response issufficient for providing the response to the prescriber computer 104.

In some embodiments, in the event of an erroneous transmission,mishandling of the prescription benefit coverage inquiry by the claimsprocessor computer 108 or other misstep, or if the response includes astatus or indication that the medication associated with theprescription benefit coverage inquiry is not covered by the patient'spharmacy benefits manager/insurance provider, the response may alsoinclude, without limitation, one or more fields comprising the patientpay amount field left blank, a reject reason field populated with arejection reason corresponding to the rejected prescription benefitcoverage inquiry (e.g., pricing not available for an identifiedscenario, reject description, or the like), an estimated cash price orrange is left blank, the pharmacy name field is left blank, a reason forservice code field populated with a reject error code, and/or a reasonfor service description field populated with an abbreviated descriptionof a corresponding reason for service code. In this regard, due tolacking or missing information in the response from the claims processorcomputer 108, the service provider computer 106 may determine that asufficient response was not received.

The response received from the claims processor computer 108 may bemissing information as described above, such as values for a patient payamount and/or the like. Additionally or alternatively, the response mayprovide indication of various circumstances in which a patient payamount and/or other necessary information may be absent from theresponse such that response is insufficient for providing to theprescriber computer 104, and determining an estimated cost range for theprescribed medication associated with the prescription benefit coverageinquiry would be beneficial in helping the prescriber provide a patientwith accurate medication cost information, as described in furtherdetail in operation 308. These circumstances may include, but are notlimited to, the following indications:

TABLE 1 Refill Too Soon Product Not Covered - Non-ParticipatingManufacturer Missing Group Number Product/Service Not Covered for GenderInactive Group Number Patient is Not Covered Non-Matched Cardholder IDRefills are Not Covered Prior Authorization Required Step Therapy,Alternate Drug Therapy Required Prior to Use of Submitted ProductService ID Product/Service Not Covered Cost Exceeds Maximum Product Noton Formulary Days Supply Exceeds Plan Limitation Product/Service NotCovered for Cardholder ID submitted is inactive Age

It will be appreciated that operation 306 may be configured and/ormodified to define different conditions that should be met for aresponse to be considered sufficient for providing to the prescribercomputer 104. The predefined conditions may be programmed by adeveloper, and/or configured by a user using user interface 216.

Continuing with the description of operation 312, performed if asufficient response is received within the predetermined amount of time,the service provider computer 106 may transmit the response to theprescriber computer 104 for display to a user, such as a physician,patient, and/or the like. In this regard, apparatus 200 may includemeans, such as processor 212, memory 214, communication interface 218,and/or the like for providing, or transmitting, a response associatedwith a prescription benefit coverage inquiry to the prescriber computer104 or other associated entity for display to a user. In some examples,the response may be forwarded to the prescriber computer 104 as providedby the claims processor computer 108. In certain example embodiments,the service provider computer 106 may modify the response provided bythe claims processor computer 108 to include additional information.

Continuing to operation 308, performed when a timeout occurs, or asufficient response is not received, apparatus 200 may include means,such as processor 212, memory 214, and/or the like, for determining anestimated cost range for the prescribed medication associated with theprescription benefit coverage inquiry. In this regard, in an instance inwhich a response from the pharmacy claims processor computer 108 is notreceived or a received response fails to satisfy a predefined condition,a cost range for the prescribed medication may be estimated as describedin further detail below with respect to FIG. 4 .

FIG. 4 provides operations associated with operation 308 and the processof determining an estimated cost range for the prescribed medication.The service provider computer 106 may determine an estimated cost rangefor the prescribed medication associated with the prescription benefitcoverage inquiry based on historical data.

At operation 400, apparatus 200 may include means, such as processor212, memory 214, and/or the like, for retrieving historical datacomprising prior prescription transactions associated with theprescribed medication. The historical data may be further associatedwith a time range, pharmacy, state and/or other criteria. For example,the service provider computer 106 may access historical data, such asdata comprising prior prescription transactions, via a database 102. Asdescribed above, data may be provided to database 102 by one or morepharmacy computers 110 and/or service provider computers 106. These oneor more pharmacies may voluntarily provide data directly or indirectlyto database 102, such as historical data related to prior prescriptiontransactions that have taken place at each respective pharmacy. In anembodiment, the one or more pharmacies may be taking part in a programwherein data associated with the one or more pharmacies, such as priorprescription transaction data, is supplied to database 102 to providepatients and prescribers with accurate cost information at a point ofprescribing. In this regard, example embodiments, such as with processor212, may search the data within the database 102 and acquire resultsbased on the prescription benefit coverage inquiry.

The prescription benefit coverage inquiry may indicate a preferredpharmacy of a patient, the state in which the preferred pharmacy islocated, prescribed medication and/or associated NDC, and/or the like.In some embodiments, the service provider computer 106 may search thedatabase 102 for prior prescription transactions (including NDC &quantity transaction combinations) that have taken place within apredefined time period and are associated with the preferred pharmacy,state of the pharmacy, and prescribed medication. For example, aprescription benefit coverage inquiry may indicate a preferred “PharmacyA”, a state in which the pharmacy is located, such as “Georgia”, and aprescribed medication “Medication X”. In the event the service providercomputer 106 fails to receive a response from the claims processorcomputer 108, or the response is erroneous and/or lacking requiredinformation, the service provider computer 106 may search the database102 for prior prescription transactions associated with “Pharmacy A”(including pharmacies included in a chain of “Pharmacy A”) in Georgia,and “Medication X” that have taken place within a predefined timeperiod, such as, for example, in the previous sixty days. In someexamples, the pharmacy computer 110 of the preferred pharmacy indicateswhat chains of pharmacies for which historical data should be accessed.The service provider computer 106 may then receive one or more resultscomprising prior prescription transactions that have taken place in theprevious sixty days at “Pharmacy A” (including pharmacies related bychain) located in Georgia regarding “Medication X”.

In certain embodiments, after the search has been performed and theresults of the search are received by service provider computer 106, theservice provider computer may then filter the results at operation 401.In this regard, the apparatus 200 may include means, such as processor212, memory 214, and/or the like, for filtering the historical data soas to exclude one or more types of prescription transactions fromconsideration based on filtering criteria.

For example, one or more prior prescription transactions within theresults that are associated with a compound drug (i.e. anon-FDA-approved combination of two or more drugs tailored to a specificindividual's needs) may be excluded, or eliminated, from the results.One or more prior prescription transactions within the results that areassociated with a Coordination of Benefits (i.e. two or more insuranceplans paying claims for the same patient) may also be excluded from theresults. Additionally, one or more prior prescription transactionswithin the results that are associated with a cash payment (i.e. therecipient paid cash out-of-pocket for medication without assistance froman insurance plan) may also be excluded from the results. As anotherexample, some filtering criteria may include filters to include onlycash transactions and to exclude prescription transactions processed bya payor. This may enable example embodiments to provide an estimatedcost range for a cash transaction. Further, one or more priorprescription transactions with the results that indicate that a patientassociated with the one or more prior prescription transactions were ina deductible stage (i.e. paying toward a deductible prior to aninsurance plan assisting) may be excluded from the results. Based on thefiltering the historical data so as to exclude one or more types ofprescription transactions from consideration, the service providercomputer 106 may obtain a filtered set of historical data comprisingprior prescription transactions.

At operation 402, the service provider computer 106 may determine anaverage value based on a paid amount associated with each prescriptiontransaction of the filtered historical data. In this regard, theapparatus 200 may include means, such as processor 212, memory 214,and/or the like, for determining an average value based on a paid amountassociated with each of the prescription transactions in the filteredhistorical data. For example, the service provider computer 106 maydetermine an average value, such as the mean, of all values associatedwith the patient pay amount field in each prior prescription transactionwithin the filtered set of historical data. Thus, the average value mayindicate an average amount paid by patients at a pharmacy in aparticular state, such as the preferred pharmacy associated with aprescription benefit coverage inquiry, for a prescribed medication, suchas the prescribed medication associated with a prescription benefitcoverage inquiry, in a predefined period of time. In the example above,the average value may indicate the average amount paid by patients at“Pharmacy A” in Georgia for “Medication X” in the past sixty days.

In an embodiment, the apparatus 200 may include means, such as processor212, memory 214, and/or the like, for determining a standard deviationor other calculated amount associated with the average value of thefiltered historical data. At operation 403, the service providercomputer may identify a subset of prescription transactions within onestandard deviation or other calculated amount of the average value. Inthis regard, the apparatus 200 may include means, such as processor 212,memory 214, and/or the like, for identifying a subset of prescriptiontransactions within the filtered historical data that comprise a patientpay amount within one standard deviation of the average value.

The service provider computer may compare each paid amount to a standarddeviation associated with the average value. In this regard, theapparatus 200 may include means, such as processor 212, memory 214,and/or the like, for comparing each paid amount to the standarddeviation to determine one or more paid amounts that are within apredefined number of standard deviations of the calculated amount. In anembodiment, the service provider computer 106 may compare each patientpay amount in each prior prescription transaction within the filteredset of results to a calculated amount to identify a subset of priorprescription transactions which comprise a patient pay amount within apredefined number of standard deviations (e.g., 1) of the average value.Identification of a subset of prescription transactions within onestandard deviation may be performed to ensure enough data is present toaccurately provide an estimated cost range. In other words, at operation404, the service provider computer 106 may determine whether theidentified subset of prescription transactions comprises enoughprescription transactions to proceed with determining an estimated costrange for the prescribed medication. In this regard, the apparatus 200may include means, such as processor 212, memory 214, and/or the like,for determining if the number of prescription transactions within theidentified subset satisfies a predefined threshold.

In the event that the number of prescription transactions within theidentified subset fails to satisfy the predefined threshold, the processmay proceed to operation 410. According to some example embodiments, ifnot enough transactions are present in the filtered historical data thatfall within a first predefined number of standard deviations (e.g., onestandard deviation) from the average value, example embodiments maydetermine that there is insufficient historical data for estimating acost range, or for estimating a cost range with a minimum thresholdlevel of confidence of accuracy, and may provide a message to theprescriber computer 104 indicating that patient benefits and/or anestimated cost range of the prescribed medication is not available. Inthis regard, the apparatus 200 may include means, such as processor 212,memory 214, and/or the like, for providing a response to the prescribercomputer 104 indicating an estimated cost range is not available for theprescribed medication associated with the prescription benefit coverageinquiry.

In the event that the number of prescription transactions within theidentified subset satisfies the predefined threshold, the serviceprovider computer 106 may determine that enough data, such as enoughprescription transactions, is available to estimate a cost range for theprescribed medication. At operation 406, the apparatus 200 may includemeans, such as processor 212, memory 214, and/or the like, for includingprior prescription transactions comprising paid amounts within a secondpredefined number of standard deviations of the average value in thesubset of prescription transactions. For example, the subset of priorprescription transactions may only comprise prior prescriptiontransactions with a patient pay amount within two standard deviations ofthe average value. In the above example, the service provider computer106 may include all prior prescription transactions with a patient payamount within two standard deviations of the average value in the subsetof prior prescription transactions.

At operation 408, once the subset of prior prescription transactionsbased on the average value has been determined, the service providercomputer may determine the estimated cost range of the prescribedmedication based on the subset of prescription transactions. In thisregard, the apparatus 200 may include means, such as processor 212,memory 214, and/or the like, for determining, from the subset ofprescription transactions, the estimated cost range of the prescribedmedication that ranges a calculated amount from the average value. Alow-end and a high-end of the estimated cost range of the prescribedmedication may be amounts that are a predefined number of standarddeviations, such as two standard deviations, from the mean in eachdirection. For example, if the average value is determined to be $50,and the standard deviation is determined to be $7.5, the estimated costrange of the prescribed medication may be determined to be a range from$35 to $65. In other words, continuing with the above example, thepatient with a preferred “Pharmacy A” in Georgia that is prescribed“Medication X” may be expected to pay between $35 and $65 for MedicationX.

Example embodiments may therefore order the filtered historicaltransactions by the transactions' respective variances from the averageor mean patient payment amount. The estimated cost range for aprescription may then be estimated as the prices that are 2 standarddeviations from the left and 2 standard deviations from the right of theaverage for the copay range.

In this regard, the filtered historical data may be further refined toreduce outliers and/or to focus the data set on data determined to yieldan accurate estimated price range of a prescription. For example,outliers such as historical transactions that include erroneous paidamounts, and/or the like, may be eliminated by identifying a subset ofthe transactions within one or more standard deviations of the averagevalue.

Returning to FIG. 3 , at operation 310, once an estimated cost range hasbeen determined by performing the example operations of FIG. 4 , theservice provider 106 may provide the estimated cost range to theprescriber computer 104 for display to a user, such as a prescriber,physician, patient, and/or the like. As such, the apparatus 200 mayinclude means, such as processor 212, memory 214, communicationinterface 218, and/or the like, for providing the estimated cost rangefor the prescribed medication to the prescriber computer for display toa user. The estimated cost range may be displayed at prescriber computer104 via user interface 216. The estimated cost range may include aplan-price (assuming submission to a claims processor computer 108 foradjudication and prescription claim payment), and/or a cash price, thecash price reflecting the cost of the prescription without submission ofan insurance claim.

In certain embodiments in which a response to a prescription benefitcoverage inquiry was received by the service provider computer 106 fromthe claims processor 108 but was determined to not be sufficient forproviding to the prescriber computer 104 due to lacking requiredinformation, the service provider computer, in addition to providing theestimated cost range for the prescribed medication, may also provideinformation relating to the received response. In other words, aprescriber may receive information regarding a potential prescriptionclaim based on the response provided by the claims processor computer108, along with an estimated cost range for the prescribed medication,as estimated according to example embodiments by service providercomputer 106.

For example, a response from the claims processor computer 108 maycomprise information indicating that prior authorization may be requiredfor a prescribed medication associated with the prescription benefitcoverage inquiry and may not comprise any type of medication costinformation because the prior authorization has not been obtained.According to example embodiments, in such a scenario, the serviceprovider computer 106 may provide the message indicative of therequirement for prior authorization, as well as provide an estimatedcost range, assuming the preauthorization is obtained, to the prescribercomputer 104 to ensure the prescriber and patient have all necessaryinformation. In this regard, certain example embodiments append anestimated cost range calculated by the service provider computer 106 toa response received from claims processor 108 to provide more meaningfulinformation to the prescriber computer 104.

Once the estimated cost range is provided to the prescriber computer104, a prescriber may review the information on a user interface andprovide the estimated cost range to the patient associated with theprescription benefit coverage inquiry. Thus, in the event a responsefrom the patient's pharmacy benefits manager is not received or lackingrequired information, the patient may be well informed of an estimatedrange for the cost of the prescribed medication at the time ofprescribing, alleviating the patient from being blindsided of unforeseencosts when attempting to fulfill the prescription at a preferredpharmacy. As an example, a patient may suggest that the estimated costrange is too burdensome for the patient, and in turn the prescriber,such as the patient's physician, may suggest or prescribe alternativemedications, and in some embodiments, provide another prescriptionbenefit coverage inquiry associated with the alternative medication inorder to provide the patient with additional cost information for thealternative medication.

Example embodiments, such as those including but not limited to thoseperforming operations described above, may therefore provide technicalimprovements over existing service provider systems, including thatattempt to provide responses from the claims processor computer 108. Asdescribed herein, prior systems may not provide any pricing informationin the event that a response to a prescription benefit coverage inquiryis not provided by a claims processor computer 108, or in the event thata response is erroneous and/or lacking required information, such as apatient pay amount. In such systems, processing resources, such asmemory and/or processing power may be utilized in receiving andsubmitting subsequent inquiries and responses by the service providercomputer 106 and/or prescriber computer 104 only to be wasted in theevent that a response from a claims processor computer 108 is neverreceived or erroneously provided. Additional processing resources, suchas memory used to store and track problem tickets, may also be requiredto facilitate the correction of such issues.

Example embodiments provide technical improvements to such systems byimplementing the apparatus 200 such that estimated cost ranges ofprescribed medication may be calculated and determined in real-time ornear real-time as the physician prescribes a medication for a patient.The term “near” real-time is used to express that a cost estimate may beprovided at the prescriber computer 104 within a fraction of a second,or seconds, from the time the prescription benefit coverage inquiry issubmitted. The technical challenges in providing this real-time feedbackare increased by the evolving complexities of healthcare transactionsand their associated processing by claims processing computers 108, andthe uncertainty or inconsistency of response quality and response timeassociated therewith. The challenges are further increased by the everincreasing volume of data received from pharmacies and/or claimsprocessors. Example embodiments leverage the historical data in a mannerdescribed herein that provides efficient, and accurate cost estimatesfor patients and physicians at the point of service.

The solutions provided by example embodiments therefore improve theusage of processing resources, and additionally or alternatively improvethe functioning of the service provider computer 106 by reducing and/oreliminating erroneous responses and reducing and/or eliminatinginstances in which prescribers and patients are left without costinformation when responses are not provided by a claims processorcomputer 108. Additionally, processing resources are further conservedby not necessarily determining an estimated cost range for everysubmission of a prescription benefit coverage inquiry, but byselectively determining an estimated cost range under certaincircumstances, such as when a response from a claims processor computer108 is not received or is insufficient for providing to the prescribercomputer 104.

Similarly, example embodiments may reduce and/or eliminate the need forprescription benefit coverage inquiry resubmissions, and/or the like,caused by users such as prescribers not understanding why a response wasnever received, and resubmitting identical prescription benefit coverageinquiries in hopes of receiving a proper response. This may thereforereduce the resources expended, such as memory and/or processing power,that may otherwise be required to facilitate the resubmission (andpossibly numerous resubmissions) of the same prescription benefitcoverage inquiry, as well as the associated rerouting, and reprocessingof the resubmitted transaction(s) throughout the various componentsdescribed herein. Likewise, example embodiments may reduce processingresources otherwise expensed on extensive research, custom queries,and/or the like, when cost estimates for prescriptions cannot otherwisebe obtained. Accordingly, example embodiments described herein furtherimprove the technical efficiency of systems implementing and/oremploying such embodiments.

It will be appreciated that the figures are each provided as examplesand should not be construed to narrow the scope or spirit of thedisclosure in any way. In this regard, the scope of the disclosureencompasses many potential embodiments in addition to those illustratedand described herein. Numerous other configurations may also be used toimplement embodiments of the present invention.

FIGS. 3-4 illustrate operations of a method, apparatus, and computerprogram product according to some example embodiments. It will beunderstood that each operation of the flowchart or diagrams, andcombinations of operations in the flowchart or diagrams, may beimplemented by various means, such as hardware and/or a computer programproduct comprising one or more computer-readable mediums having computerreadable program instructions stored thereon. For example, one or moreof the procedures described herein may be embodied by computer programinstructions of a computer program product. In this regard, the computerprogram product(s) which embody the procedures described herein maycomprise one or more memory devices of a computing device (for example,memory 214) storing instructions executable by a processor in thecomputing device (for example, by processor 212). In some exampleembodiments, the computer program instructions of the computer programproduct(s) which embody the procedures described above may be stored bymemory devices of a plurality of computing devices. As will beappreciated, any such computer program product may be loaded onto acomputer or other programmable apparatus (for example, apparatus 200) toproduce a machine, such that the computer program product including theinstructions which execute on the computer or other programmableapparatus creates means for implementing the functions specified in theflowchart block(s). Further, the computer program product may compriseone or more computer-readable memories on which the computer programinstructions may be stored such that the one or more computer-readablememories can direct a computer or other programmable apparatus tofunction in a particular manner, such that the computer program productmay comprise an article of manufacture which implements the functionspecified in the flowchart block(s). The computer program instructionsof one or more computer program products may also be loaded onto acomputer or other programmable apparatus (for example, apparatus 200and/or other apparatus) to cause a series of operations to be performedon the computer or other programmable apparatus to produce acomputer-implemented process such that the instructions which execute onthe computer or other programmable apparatus implement the functionsspecified in the flowchart block(s).

Accordingly, blocks of the flowchart support combinations of means forperforming the specified functions and combinations of operations forperforming the specified functions. It will also be understood that oneor more blocks of the flowchart, and combinations of blocks in theflowchart, can be implemented by special purpose hardware-based computersystems which perform the specified functions, or combinations ofspecial purpose hardware and computer instructions.

Many modifications and other embodiments of the inventions set forthherein will come to mind to one skilled in the art to which theseinventions pertain having the benefit of the teachings presented in theforegoing descriptions and the associated drawings. Therefore, it is tobe understood that the inventions are not to be limited to the specificembodiments disclosed and that modifications and other embodiments areintended to be included within the scope of the appended claims.Moreover, although the foregoing descriptions and the associateddrawings describe example embodiments in the context of certain examplecombinations of elements and/or functions, it should be appreciated thatdifferent combinations of elements and/or functions may be provided byalternative embodiments without departing from the scope of the appendedclaims. In this regard, for example, different combinations of elementsand/or functions than those explicitly described above are alsocontemplated as may be set forth in some of the appended claims.Although specific terms are employed herein, they are used in a genericand descriptive sense only and not for purposes of limitation.

That which is claimed:
 1. An apparatus comprising one or more processorsand at least one memory including computer program code, that whenexecuted by the one or more processors, causes the one or moreprocessors to perform steps of: storing a time threshold and a historyof prescription transactions; receiving, from a prescriber computer, aprescription benefit coverage inquiry associated with a patient and aprescribed medication; transmitting the prescription benefit coverageinquiry to a pharmacy claims processor computer; monitoring a networkfor receipt of a response associated with the prescription benefitcoverage inquiry from the pharmacy claims processor computer; receivinga response from the pharmacy claims processor computer over themonitored network; determining whether a response from the pharmacyclaims processor computer is received within the time threshold; basedon a determination that the response from the pharmacy claims processorcomputer is not received within the time threshold, and further based onthe stored history of prescription transactions, generating an estimatedcost range for the prescribed medication and transmitting the generatedcost range to the prescriber computer; and based on a determination thatthe response from the pharmacy claims processor is received within thetime threshold, transmitting the received response to the prescribercomputer, wherein the response includes a pay amount field comprising avalue.
 2. The apparatus of claim 1, wherein the computer program code,when executed by the one or more processors, further causes the one ormore processors to perform a step of: excluding one or more types ofprescription transactions from consideration by filtering the historicaldata.
 3. The apparatus of claim 1, wherein generating the estimated costrange comprises: determining an average value based on a paid amountassociated with each of the prescription transactions in the historicaldata; identifying a subset of prescription transactions from thehistorical data based on the average value; and from the subset ofprescription transactions, determining the estimated cost range of theprescribed medication that is within a range of the average value. 4.The apparatus of claim 3, wherein identifying a subset of prescriptiontransactions from the historical data based on the average valuecomprises: comparing each paid amount to an amount associated with theaverage value and determining one or more paid amounts that are within apredefined range of the amount; and including, based on the comparison,that transactions comprising paid amounts within the predefined range ofthe amount in the subset of prescription transactions.
 5. The apparatusof claim 1, wherein transmitting the generated cost range to theprescriber computer is performed in real-time or near real-time relativeto receiving the prescription benefit coverage inquiry.
 6. A computerprogram product comprising at least one non-transitory computer-readablestorage medium having computer-executable program code instructionsstored therein, that when executed by one or more processors, cause theone or more processors to perform steps of: storing a time threshold anda history of prescription transactions; receiving, from a prescribercomputer, a prescription benefit coverage inquiry associated with apatient and a prescribed medication; transmitting the prescriptionbenefit coverage inquiry to a pharmacy claims processor computer;monitoring a network, by the one or more service provider computers, forreceipt of a response associated with the prescription benefit coverageinquiry from the pharmacy claims processor computer; receiving aresponse from the pharmacy claims processor computer over the monitorednetwork; determining whether a response from the pharmacy claimsprocessor computer is received within the time threshold; based on adetermination that the response from the pharmacy claims processorcomputer is not received within the time threshold, and further based onthe stored history of prescription transactions, generating an estimatedcost range for the prescribed medication and transmitting the generatedcost range to the prescriber computer; and based on a determination thatthe response from the pharmacy claims processor is received within thetime threshold, transmitting the received response to the prescribercomputer, wherein the response includes a pay amount field comprising avalue.
 7. The computer program product of claim 6, wherein thecomputer-executable program code instructions that when executed by theone or more processors, further cause the one or more processors toperform a step of: excluding one or more types of prescriptiontransactions from consideration by filtering the historical data.
 8. Thecomputer program product of claim 6, wherein generating the estimatedcost range comprises: determining an average value based on a paidamount associated with each of the prescription transactions in thehistorical data; identifying a subset of prescription transactions fromthe historical data based on the average value; and from the subset ofprescription transactions, determining the estimated cost range of theprescribed medication that is within a range of the average value. 9.The computer program product of claim 8, wherein identifying a subset ofprescription transactions from the historical data based on the averagevalue comprises: comparing each paid amount to an amount associated withthe average value and determining one or more paid amounts that arewithin a predefined range of the amount; and including, based on thecomparison, that transactions comprising paid amounts within thepredefined range of the amount in the subset of prescriptiontransactions.
 10. The computer program product of claim 6, whereintransmitting the generated cost range to the prescriber computer isperformed in real-time or near real-time relative to receiving theprescription benefit coverage inquiry.